The Sustainable Growth Formula was initially devised to give doctors increased Medicare reimbursement if medical costs go down and decrease reimbursement if costs rise. The formula was quickly found to be flawed. Individual physicians cannot control the overall trajectory of Medicare expenses regardless of the financial rewards or penalties. The formula failed to take into account overall increases in costs we have experienced over the past decade as a result of an aging population and new medical technology. As a result, the formula would reduce Medicare payments to physicians to a level below what doctors could afford to see Medicare patients for. Reimbursement from Tricare, which covers military families, is also tied to Medicare reimbursement. Congress has realized that the cuts were not tolerable and has repeatedly voted for a “doc fix” to circumvent the automatic cuts called for under the Sustainable Growth Formula.

The persistence of this problem over the past decade has eroded confidence in the federal government and the Medicare program, leading some physicians to stop accepting Medicare patients. Even Congress finally realized that something had to be done and an agreement was reached in principle between the federal government and physician organizations for a new payment structure to replace the Sustainable Growth Formula. The House had the opportunity to pass this as a clean bill today, but instead played politics by attaching it to a delay to the individual mandate.

It is getting difficult to keep count but I believe this is now the fifty-first vote to either repeal or greatly interfere with the implementation of the Affordable Care Act.

The individual mandate is a necessary component of the Affordable Care Act as currently structured. If insurance companies are required to provide coverage to everyone applying, they need protection against the problem of people not buying insurance until they become ill. In order for the system to function, insurance companies need the premiums from healthy people coming into the system every year to cover the expenses of those who are ill.

There are potentially other ways to solve the free rider problem but it is not possible to simply eliminate the individual mandate without implementing alternative measures to provide strong incentives for people to purchase insurance coverage while still healthy. While I had preferred using other measures instead of the mandate when health care reform was being considered, unlike the House Republicans I recognize when an issue has been settled and see no sense in continuing to fight the same battle. The Affordable Care Act is established law which has been upheld by the Supreme Court. Congress should be concentrating on making some necessary fixes (as any law of this complexity would require) to smooth its implementation as opposed to trying to sabotage it.

Twelve Democrats voted with the Republicans out of political fears. The Affordable Care Act is turning into a major success, providing millions with health insurance coverage and ending the ability of insurance companies to abuse the system by finding ways to sell policies and then avoid paying out. In addition, Obamacare frees people from the “insurance trap” which forced people who otherwise do not need to work to continue working for insurance coverage, along with other overall benefits to the economy. The Congressional Budget Office Report, frequently distorted by Republicans, showed that the Affordable Care Act will reduce unemployment, help decrease the deficit, and allow more people to leave large corporations to start small businesses, further stimulating the economy.

Despite all of these benefits, Democrats remain on the defensive politically. While granted the Republicans have a strong propaganda machine delivering their misinformation, and a media willing to repeat Republican lies as if they are equally valid as statements of fact, Democrats should be able to do a better job of gaining support when the facts are so firmly on their side. The same is true of health care issues in general, as Republicans have managed to put Democrats on the defensive over bogus claims of Medicare cuts while the Republicans seek to turn Medicare into a voucher system which would destroy the program as we know it.

Begala thinks Dems can address it with a simple flipping of the script. Dems now debating how to talk about Obamacare seem to be leading defensively with their willingness to fix the law. Instead, Begala says, they should lead with an attack on Republicans that is framed as a medical rights issue – before pivoting to fixing the law — and then wrap it all up in a larger message about how Republicans have no answers to people’s health care or economic problems.

“We should open by saying, ‘my opponent wants to repeal your rights,’” Begala said. “He wants to take away your right to be protected against discrimination because you have a preexisting condition. He wants to take away your right to be protected against discrimination for being older or being a woman. He wants to take away the closing of the Medicare donut hole for seniors.”

“That’s point one,” he continued. “Then you say, ‘look, I’m open to working with everybody to fix the law. But I’ll never let them go back to the days where insurance companies could send letters saying your coverage has been canceled because you have a preexisting condition.’”

And then from there to an economic message: “Repeal is their whole agenda. They have no ideas for giving you a pay raise. No ideas for raising the minimum wage. No ideas about how to create jobs. No ideas about how to get your kid into pre-K. Their entire agenda as a party is repeal — to take away rights that you have won. I’m not going to let them do that.”

All Democrats should have also stood up for both physicians and Medicare patients today and demanded a clean vote on the repeal of the Sustainable Growth Formula as opposed to tying it to yet another attempt to thwart Obamacare. If Democrats did something as silly as vote over fifty times to repeal the same thing while otherwise failing to legislate, imagine how the right wing noise machine would be mocking them.